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1/17/2017
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Polypharmacy –Preventing Unnecessary Medications for Older Adults
Robert Sonntag MD, CMD, HMDC
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F329 in review
Each residents drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
In excessive dose (including duplicate drug therapy); or
For excessive duration; or
Without adequate monitoring; or
Without adequate indications for its use; or
In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
Any combinations of the reasons above.
This portion of the regulation applies to all medications, not just antipsychotics.
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Polypharmacy
“As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral”
Jerry Avorn, quoted in Arch Intern Med 164:1957–59
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Polypharmacy
“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”
Sir William Osler, in H. Cushing, Life of Sir William Osler (1925)
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Polypharmacy
“I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”
Oliver Wendell Holmes, 1860
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Rx Use and Seniors
Typical NF Resident
75-85+ years of age
Average number of routine prescription medications: 8.1
Average number of PRN prescription medications: 3.2
Percent of residents receiving 9+ routine medications per day: 41.1
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Living in ALF
Rehab
Hospice
Back to ALF!
“A Cautionary Tale”
Fall, Fracture
Deprescribing
JAMA Intern Med. 2015;175(11):1750-1751.
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Adverse Effects
“Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”
Gurwitz J, Monane M, Monane S, Avorn J. Polypharmacy. In: Morris JN, Lipsitz LA, Murphy K, et al. Quality Care in the Nursing Home. St. Louis, MO: Mosby Year Book;1997:13-25.
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Adverse Drug Reactions
An adverse drug reaction (ADR) is defined as the unwanted, negative consequences associated with the use of a medications or medications.
Over 100,000 deaths a year are attributed to adverse drug reactions, making ADRs the fourth leading cause of death in the U.S. (Lazarou, Pomeranz, & Corey, 1998).
Other examples of ADRs include: Peptic ulcers Anemia Deceased white blood cell production (which increases
infection risk) Liver damage Kidney damage Confusion/drowsiness (which can lead to falls and
subsequent injuries)
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Adverse Drug Reactions
About 3 to 7% of all hospital admissions in the United States are for treatment of adverse drug reactions.
Adverse drug reactions occur during 10 to 20% of hospital admissions, and about 10 to 20% of these reactions are severe.
The most consistent risk factor for an adverse drug reactions is:
The number of drugs being taken.
The risk increases exponentially as the number of drugs increases as illustrated in the following chart…
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1
10
100
0 2 4 6 8 10 12 14 16 18 20
number of drugs taken
percen
t o
f p
ati
en
ts w
ith
AD
R
Adverse Drug Reactions
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Adverse Drug Reactions
Other risk factors for ADRs include:
Having six or more chronic diseases.
Taking twelve or more doses of medication (of any type) per day.
Taking nine or more medications total.
Having had a prior adverse drug reaction.
Being older than 85 years (this is important because persons 85 and older are the fastest growing segment of the population).
Having decreased kidney function.
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Most Common Medications Associated with ADRs in the Elderly
Opioid analgesics
NSAIDs
Anticholinergics
Benzodiazepines
Also: cardiovascular agents, CNS agents, and musculoskeletal agents
Adverse Drug Reaction Risk Factors in Older Outpatients. Am J Ger Pharmacotherapy 2003;1(2):82-89.
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Prescribing Cascade
Drug 1
ADE interpreted as new medical condition
Drug 2
ADE interpreted as new medical condition
Drug 3
Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people: the prescribing cascase. BMJ 1997;315:1097.
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New Paradigm for Geriatric Drug Treatment
Old: “Start Slow, Go Slow”
New: “Stop Most, Reduce Dose”
Garfinkel, IMAJ, 2007
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HOW TO USE THE AGS 2015 BEERS CRITERIA
A GUIDE FOR PATIENTS, CLINICIANS, HEALTH SYSTEMS, AND PAYORS
A CLINICIAN EDUCATION TOOL
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Optimizing Use of the Beers Criteria: A Guide
As part of 2015 update of the Beers Criteria, AGS created a workgroup to encourage optimal use of the criteria by patients, clinicians, health systems, and payors
Included input from key stakeholders
Workgroup developed:
7 key principles to guide optimal use of the criteria
Guidance for how clinicians and others can apply these principles in everyday practice
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What is the Purpose of the Beers Criteria?
To identify potentially inappropriate medications that should be avoided in many older adults
To reduce adverse drug events and drug related problems, and to improve medication selection and medication use in older adults
Designed for use in any clinical setting; also used as an educational, quality, and research tool
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Benefits and Challenges
However, implementation of the Beers Criteria has led to several unintended consequences
Many clinicians misunderstand the purpose of the criteria, mistakenly believing that the criteria judge all uses of the listed drugs to be universally inappropriate
Health systems have often reinforced this perception, implementing quality improvement and decision support systems that implicitly consider any use of these medications to be problematic
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7 Key Principles
There are 7 key principles to guide optimal use of the Beers Criteria
But, the most important take-home message is this:
Use clinical common sense!
The Beers criteria are intended to support, not contradict, common sense and good clinical care
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7 Key Principles
1. Medications in the AGS 2015 Beers Criteria are potentially
inappropriate, not definitely inappropriate
2. Read the rationale and recommendations for each criterion
3. Understand why a medication is included in the Criteria and adjust
your approach to these medications accordingly
4. Optimal use of the 2015 Beers Criteria involves offering safer non -
pharmacologic and pharmacologic therapies
5. 2015 Beers criteria should be a starting point for identifying and
improving medication safety and appropriateness
6. Medications in the 2015 Beers criteria should not be excessively
restricted by PA and/or health plan policies
7. The 2015 Beers criteria are not equally applicable to all countries
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2015: A New Brew of Beers
PIMS CAUTION
Anti-
Cholis
Dangerous
LiaisonsKidney
Brew
Drug-
Disease
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Medications to AVOID-Quality of Evidence: HIGH; Strength of Recommendation: STRONG
Therapeutic Class:
Class: Example Medications:
Antidepressants
Tricyclicsclomipramine, desipramine, imipramine, nortriptyline, amitriptyline, doxepin > 6 mg/day
SSRIs paroxetine
Sedative/Hypnotic
Barbituratesamobarbital, butalbital, pentobarbital, phenobarbital, secobarbital
Cardiovascular
Antiarrhythmic dronedarone, amiodarone
Calcium channel blocker
nifedipine (immediate release)
Vasodilator isoxsuprine, ergot mesylates
Reproductive health
Hormonesoral and transdermal estrogens, growthhormone
Antidiabetic Sulfonylureas chlorpropamide, glyburide
GIProton pump
inhibitorspantoprazole, omeprazole, lansoprazole, etc
PIMS
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Medications to AVOID-Quality of Evidence: Moderate; Strength of Recommendation: STRONG
Therapeutic Class:
Class: Example Medications:
Anticholinergics
First-generation antihistamines
chlorpheniramine, diphenhydramine, doxylamine, hydroxyzine, meclizine, promethazine
Antiparkinson agents benztropine, trihexyphenidyl
Anitspasmodicsbelladonna alkaloids, chlordiazepoxide, dicyclomine, hyoscyamine, scopolamine
Cardiovascular
Antiplateletsdipyridamole (short-acting)
ticlodipine
Alpha-1 blockers doxazosin, prazosin, terazosin
Inotropedigoxin for atrial fibrillation or doses >0.125 mg/day
PIMS
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Medications to AVOID-Quality of Evidence: Moderate; Strength of Recommendation: STRONG
Therapeutic Class:
Class: Medications:
AntipsychoticsTypical (1st-gen) haloperidol, chlorpromazine, thioridazine
Atypical (2nd-gen)quetiapine, aripiprazole, olanzapine, risperidone, clozapine
Anti-anxietyBenzodiazepines
alprazolam, lorazepam, oxazepam, temazepam, chlordiazepoxide, clonazepam, diazepam
Miscellaneous meprobamate
Sleep agentsNonbenzodiazepine
hypnoticseszopiclone, zolpidem, zaleplon
Antidiabetic Insulin Sliding scale
Appetite stimulant
Hormone megestrol
GIProkinetic metoclopramide
Laxative mineral oil
PIMS
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Medications to AVOID-Quality of Evidence: Moderate; Strength of Recommendation: STRONG
Therapeutic Class:
Class: Medications:
Analgesics
Opioids meperidine
Non-COX-selectiveNSAIDs
ASA > 325 mg/d, diclofenac, diflunisal, etodolac, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac
Skeletal muscle relaxants
carisoprodol, cyclobenzaprine,metaxalone, methocarbamol
GU Hormone vasopressin
PIMS
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Medications to AVOID-Quality of Evidence: low; Strength of Recommendation: STRONG
Therapeutic Class:
Class: Example Medications:
Antiinfective Miscellaneous antibiotics nitrofurantoin
Cardiovascular
Antiarrhythmics disopyramide
Alpha-agonists clonidine, guanfacine, methyldopa
Central monoamine-depleting agents
reserpine > 0.1 mg/day
Endocrine Hormones dessicated thyroid
Sleep agent Hypnotics chloral hydrate
Analgesics Opioids pentazocine
PIMS
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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CrCl < 30 mL/minAmiloride
DabigatranDuloxetineEdoxaban*
FondaparinuxProbenecidRivaroxaban
SpironolactoneTramadol ERTriamterene
CrCl < 25 mL/minApixaban
CrCl ≤ 80 mL/minLevetiracetam
CrCl < 60 mL/minGabapentin Pregabalin
CrCl < 50 mL/minCimetidineFamotidineNizatidineRanitidine
CrCl 30 - 50 mL/minEdoxaban
Rivaroxaban
CrCl < 30 mL/minEnoxaparinTramadol IRColchicine
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
Kidney
Brew
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Anti-
Cholis
Antihistamines:BrompheniramineChlorpheniramineCyproheptadineDimenhydrinate
DiphenhydramineDoxylamineHydroxyzine
MeclizinePromethazine
Antidepressants:Amitripyline
ClomipramineDesipramine
Doxepin > 6 mgImipramine
NortriptylineParoxetine
Antipsychotics:Chlorpromazine
ClozapineLoxapine
OlanzapinePerphenazineThioridazine
Trifluoperazine
Antimuscarincs:Darifenacin
FesoterodineOxybutyninSolifenacinTolterodineTrospium
Antispasmodics:Atropine
Belladonna alkaloidsClidinium
DicyclomineHyoscyamineScopolamine
Antiparkinson agents:Benztropine
Trihexyphenidyl Skeletal Muscle Relaxants:Cyclobenzaprine
Orphenadine
J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702
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Anticholinergic Cognitive Burden (ACB) Scale
1 pointAlprazolamAripiprazole
AtenololBupropionDiazepamFentanyl
FurosemideHaloperidolLoperamideMorphine
PrednisoneTrazodoneWarfarin
2 pointsCarbamazepineCyclobenzaprine
MeperidineOxcarbazepine
3 pointsAmitriptyline
AtropineBenztropine
ChlorpheniramineChlorpromazine
ClozapineDarifenacinDicyclomine
DiphenhydramineDoxepin
DoxylamineFesoterodineHydroxyzineHyoscyamineImipramineMeclizine
3 pointsMethocarbamol
NortriptylineOlanzapine
OrphenadrineOxybutyninParoxetine
PerphenazinePromethazine
QuetiapineScopolamineSolifenacin
ThioridazineTolterodine
TriheyphenidylTrospium
Agingbraincare.org
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• Increased risk of cognitive impairment (46% increase in 6 years)
• Decline in MMSE over 2 years
• 26% increase in risk of death per point over 2 years
• ACB score 5+ scored 4% lower on MMSE
What’s in a point on the ACB scale?
Agingbraincare.org
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• Delirium
• Falls
• Reduced functional status
• Impaired motor function
• Anticholinergic (AC) side effects
What’s the big deal in the short term?
Palliative Medicine 2009; 23: 257-65
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Drug-Drug Interactions (DDIs)
• May lead to adverse drug events
• Likelihood as number of medications
• Most common DDIs:– cardiovascular drugs
– psychotropic drugs
• Most common drug interaction effects:– confusion
– cognitive impairment
– hypotension
– acute renal failure
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Common Drug-Drug Interactions
Combination Risk
ACE inhibitor + potassium Hyperkalemia
ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension
Digoxin + antiarrhythmic Bradycardia, arrhythmia
Digoxin + diuretic
Antiarrhythmic + diuretic
Electrolyte imbalance; arrhythmia
Diuretic + diuretic Electrolyte imbalance; dehydration
Benzodiazepine + antidepressant
Benzodiazepine + antipsychotic
Sedation; confusion; falls
CCB/nitrate/vasodilator/diuretic Hypotension
Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996;44(9):944-948.
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Common Drug-Disease Interactions
Combination Risk
NSAIDs + CHF
Thiazolidinediones + CHF
Fluid retention; CHF exacerbation
BPH + anticholinergics Urinary retention
CCB + constipation
Narcotics + constipation
Anticholinergics + constipation
Exacerbation of constipation
Metformin + CHF Hypoxia; increased risk of lactic acidosis
NSAIDs + gastropathy Increased ulcer and bleeding risk
NSAIDs + HTN Fluid retention; decreased effectiveness of diuretics
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AGS Beers Criteria Resources
Criteria• AGS 2015 Updated Beers Criteria• How-to-Use Article• Alternative Medications List• Evidence Table Index for AGS 2015 Updated Beers Criteria• Updated Beers Criteria Teaching Slide in GRS Teaching Slides Set• Updated Beers Criteria Pocket Card • Updated Beers Criteria in iGeriatrics App
Public Education Resources for Patients & Caregivers• AGS Beers Criteria Summary • 10 Medications Older Adults Should Avoid• Avoiding Overmedication and Harmful Drug Reactions• What to Do and What to Ask Your Healthcare Provider if a Medication You Take is
Listed in the Beers Criteria• My Medication Diary - Printable Download• Eldercare at Home: Using Medicines Safely - Illustrated PowerPoint Presentation
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ABIM: CHOOSING WISELY CAMPAIGNAGS: Top Ten Things Physicians and Patients Should Question
Medications (2013)
1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding
2. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia
3. Avoid using medications to achieve Hgb A1C <7.5% in most adults age 65 and older: moderate control is better
4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, delirium
5. Don’t use antimicrobials to treat bacteriuria in older patients unless specific urinary tract symptoms are present
• www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society
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ABIM: CHOOSING WISELY CAMPAIGNAGS: Top Ten Things Physicians and Patients Should Question
Medications (2014)
6. Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse GI effects
7. Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (w PSA test) without considering life expectancy and the risks of testing, overdiagnosis and over treatment
8. Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations.
9. Don’t prescribe a medication without conducting a drug regimen review.
10. Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium
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STOPP (Screening Tool of Older Person’s Prescriptions)
1. Comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people
2. Considered as a valid, reliable comprehensive screening tool that enables the prescribing physician to appraise an older patient’s prescription drugs in the context of the patients concurrent diagnoses
3. STOPP criteria are associated with avoidable ADE’s in older people that cause or contribute to urgent hospitalization
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Principles of Prescribing in the Elderly
Avoid prescribing prior to diagnosis
Start with a low dose and titrate slowly
Avoid starting 2 agents at the same time
Reach therapeutic dose before switching or adding agents
Consider non-pharmacologic agents
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Prescribing Appropriately
Determine therapeutic endpoints and plan for assessment
Consider risk vs. benefit
Avoid prescribing to treat side effect of another drug
Use 1 medication to treat 2 conditions
Consider drug-drug and drug-disease interactions
Use simplest regimen possible
Adjust doses for renal and hepatic impairment
Avoid therapeutic duplication
Use least expensive alternative
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Anticipate Side Effects
Narcotics
begin stimulant laxative
docusate not sufficient
Steroids
osteoporosis prevention
hyperglycemia
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Feasibility of Discontinuation of Medications
256 of 311 medication recommendations were discontinued in 64 patients
Only 6 of 256 drugs discontinued were restarted (2%)
Taking nonconsent and failures together successful discontinuation was achieved in 81% of the suggested medications
No significant adverse events or deaths
88% of patients reported global improvements in health
Garfinkel :Archives of Intern Med/vol 170 Oct 11, 2010
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Guidelines for Stopping Drugs
1) Anti Hypertensions: Stop One at a Time Goal BP < 160/90
2) Nitrates: No Chest Pain for 6 Months
3) H2 Blockers and PPI’s: No Proven PUD, GI Bleeding or
Dyspepsia for 1 Year
4) All Benzodiazepines: Taper and Discontinue
5) All NSAID
Garfinkel, Arch IM, 2010
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Some of My Favorites
1. Norvasc and multiple antihypertensive
2. Anticholinergics as antispasmodics and muscle relaxants
3. Colace
4. Anti dementia drugs
5. Benzodiazepines and hypnotics
6. Sliding scale insulin
7. MVI’s and supplements
8. PRN’s in general
9. Multiple laxatives
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Other Drugs to Consider for Discontinuation
Oral Hypoglycemics
Lipid Lowering Agents (Statins)
Antidepressants
Antipsychotics
Levodopa
Anticoagulants
ASA
Iron Supplements
Osteoporosis Drugs
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Antipsychotic agents
Conventional and Atypical
Antidepressants (TCA, SSRIs, second-generation)
Anxiolytics and hypnotics (barbiturates, chloral hydrate, non-BZD sedatives)
Opioids
Benzodiazepines
Anticonvulsants
Antiemetics
Centrally-acting muscle relaxants
Anticholinergic antiparkinson drugs
Sedating Medications
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Preventing Polypharmacy
Review medications regularly and each time a new medication is started or dose is changed
Maintain accurate medication records (include vitamins, OTCs, and herbals)
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Chart Jeopardy
Medical Director and DON/ NURSE random chart review.
Applying geriatric and pharmacological principles to the medication list.
Diagnosis
Dose
Drug combinations.
Identify inappropriate and ineffective medications.
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Chart Jeopardy – Case #1
61 year old diagnosed with CVA, hospitalized with somnolence, weakness, pneumonia twice, blood pressure 120/68.
Aspirin 325 mg po qd
Carisoprodol 350 mg po qid
Cymbalta 60 mg po BID
Lasix 40 mg po qd
Novolog 70/30 give 38 units before breakfast and 20 units before supper
Duoneb qid
Keppra 750 mg po BID
Levaquin 250 mg po qd
Lisinopril 2.5 mg po qd
Oxycontin 20 mg po q 12 hrs
Klor-con 20 meq po qd
Simvastatin 80 mg po q hs
Trazadone HCL 50 mg po q hs
Diazepam 10 mg po bid prn anxiety
Percocet 1-2 tabs po qd prn
Promethazine 6.25 mg po bid prn cough
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Chart Jeopardy – Case #2
80 year old female diagnosed with dementia, hypertension, pedal edema, blood pressure 132/76
Aricept 10 mg po qd
Norvasc 5 mg po qd
Lasix 20 mg po qd
Senokot S tabs 1 po qd prn
Oxybutinin XL 10 mg po qd
Seroquel 25 mg po q 6 hours prn resistiveness to cares
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Chart Jeopardy – Case #3
79 year old male diagnosed with diabetes, CHF, CAD, and dementia – living in ltc
Lantus 20 units SQ bid
Novolog SS SQ after meals and HS for blood glucose over 150
Lasix 20 mg po bid
KCL 10 meq po qd
Plavix 75 mg po qd
Norvasc 10 mg po qd
Lisinopril 2.5 mg po qd
Imdur 30 mg po qd
Glucotrol 5 mg po qd
Trazadone 25 mg po q HS prn sleep
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Chart Jeopardy – Case #4
72 year old in tcu with tka, otherwise healthy, only pre-surgery med was antidepressant
Aspirin 325 mg po qd
Colace 100 mg po qd
Ferrous Sulfate 324 mg po tid
Senna –S tabs 1-4 po bid prn
Tylenol 325 mg tabs 1-2 po qid pain
Prozac 20 mg po qd
Vicodin tabs 1-2 po q 4-6 hours prn pain
Ambien 5 mg po q HS prn sleep
Vistaril 25 mg po tid prn pain
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Barriers to success
Resident
Medical Provider
Family
“I’ve taken that medication since I was in my 50’s.”
“Mom needs that medication, her doctor she saw for years told her she’d always need it.”
“I’m not the one who started that medication so I’m reluctant to discontinue it.”
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Barriers to success
Patients
Families
Providers
Disease specific guidelines
Goals of care not well articulated
Rehospitalization
Defining of palliative care
Lack of research in stopping medications
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Lack of research
Information is coming forward:
Acceptable to allow blood pressure readings to trend higher (160/90) in the elderly;
Hemoglobin A1C levels to increase to 8% rather than insisting on tight glycemic control.
Little information published regarding effects of stopping/reducing medications in the elderly.
There is no magic age for:
When do people no longer need statin medications?
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Fear
Fear of negative patient outcome when decreasing or stopping medication.
Reluctance to trial reduction based on this fear when in reality the medication can be resumed when disease worsens, symptoms recur depending upon goals of care.
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In Summary
You find what you “expect” to see.
Identification and decrease of inappropriate medications is feasible.
Although no absolute guidelines exist for discontinuing medications frameworks do exist.
Consensus needs to be built within facility staff and with medical providers.
Reducing medications will be an ongoing challenge.
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References Gallagher P, O’Mahony, D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to
acutely ill elderly patients and comparison with Beers’ criteria. Age and Aging 2008: 1-7
Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Arch Intern Med/Vol 170(No. 18), Oct 11, 2010
Barry PJ, Gallagher P, Ryan C, O’Mahoney D. START (screening tool to alert doctors to the right treatment)-an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Aging 200736:632-638
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. AHRQ Research in Action, Issue 1.
AGS 2015 Updated Beers Criteria JAGS 2015
AGS 2015 Alternative Medications for Medications in the use of High-Risk Medications in the Elderly and Potentially harmful Drug-disease Interactions in the Elderly Quality Measures JAGS 2015
AGS 2015 How to Use the AGS 2015 Beers Criteria- A Guide for Patients, Health Systems, and Payors JAGS 2015
Scott, Gray, Martin and Mitchell. Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework AJM ,Vol 125, No 6 June 2012
McPherson and Lockman. Lets Order Lunch off the Beers List and other Flagrant Medication Decisions in Advanced Illness A presentation at 2016 AAHPM Annual Assembly ( permission granted to use slides)
Aging Brain Care www.agingbraincare.org
Gnjidic et al : Deprescribing Trials: Methods to reduce polypharmacy and the impact on prescribing and clinical outcomes ClinGeriatric med 28(2012) 237-253
Scott et al : Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework
Cherubini Polypharmacy in Nursing Home residents: What is the Way Forward? Jamda 17(2016) 4-6
Morley : Inappropriate Drug Prescribing and Polypharmacy are major Causes of Poor Outcomes in LTC, Jamda 15 (2014) 780-782
Elliott and Stehlik: Identifying Inappropriate Prescribing for Older People, J of Pharmacy and Research vol 43, No4 2013